Cognitive Therapy

Summary of an article in the Archives of General Psychiatry that has caused a stir

In a study published in the October 2011 issue of Archives of General Psychiatry, Grant and colleagues report on 60 schizophrenia patients who were randomized into equal groups to receive standard therapy (ST) with or without cognitive therapy (CT) for 18 months, and assessed for functional and symptom outcomes at six-month intervals.

These are some of the ' presentation summaries and comments on the internet

John Gever, Senior Editor, MedPage Today
Published: October 03, 2011

Grant and colleagues based their approach on a hypothesis that negative symptoms result from a cycle of despair in patients with schizophrenia -- they develop dysfunctional beliefs about their condition that leave them pessimistic about the likely outcomes of treatment and their abilities to live normally in society. These beliefs then become self-fulfilling.

The therapy they designed took "a person-oriented therapeutic approach by highlighting the patients' interests, assets, and strengths," they wrote in their report. "We focused our treatment methods on identifying and promoting concrete goals for improving quality of life and reintegration into society."

Patients meeting DSM-IV criteria for schizophrenia or schizo-affective disorder were included if they had prominent negative symptoms without neurological disease or physical handicaps that would interfere with study participation.

Of 177 patients initially considered for participation, 55 refused, 44 failed to meet inclusion criteria, and 18 could not be included for other reasons.

With 60 available to participate, 31 were randomized to cognitive therapy plus standard treatment and the remaining 29 to standard treatment alone. Participants were assessed at six, 12, and 18 months after starting the trial with standard scales for positive and negative schizophrenia symptoms.

Standard treatment was provided by community physicians. In all cases it included drug therapy, but most patients also received other services from community mental health centers such as counseling, peer support, and vocational rehabilitation.

The cognitive therapy consisted of weekly individual sessions lasting 50 minutes, delivered by doctoral-level therapists, and continuing for the full 18 months of the study.

Ten patients in the cognitive therapy group and 11 in the control arm failed to complete the study. Outcomes were reported on an intent-to-treat basis with a hierarchical linear model for taking account of noncompleters. For global functioning, this analytical method produced a treatment difference of 9.0 points favoring cognitive therapy (95% CI 0.98 to 17.11). There was also a significant advantage for cognitive therapy in a composite measure of positive symptoms (-7.7 points, 95% CI -14.97 to -0.50). At baseline, scores averaged 21 points in the control group and 14 among those assigned to cognitive therapy.

Four negative symptoms were evaluated individually. The only one with a significant difference between groups over the 18-month study duration was avolition-apathy, favouring cognitive therapy by -0.9 points (95% CI -1.64 to -0.18) from a baseline of about 3.2.

The CT group was significantly younger, which was controlled for in the analyses. Global functioning improved in the CT group over the course of the study, whereas the ST group improved very little

Researchers adapted the cognitive program to focus on the patients' interests, assets and strengths. The intervention was intentionally designed to promote recovery by helping patients identify and achieve concrete goals for improving quality of life and reintegration into society. Treatment targeted specific defeatist beliefs ("if I partially fail it is as bad as being a complete failure") that earlier research has identified as blocks to patients engaging in constructive activity.

After 18 months of therapy, patients in the cognitive therapy group were encouraged to set goals related to their everyday functioning. Researchers observed that as they became motivated to engage in tasks they moved out of their withdrawn state. This increase in activity and motivation put the patients more in touch with reality and reduced hallucinations, delusions, and disorganized speech. The cycle continued as engagement in activity led to better functional outcomes and motivation, which facilitated continued improvement of symptoms.

This is the first time, to our knowledge, that patients with chronic schizophrenia selected from the extreme end of the low-functioning continuum have shown statistically significant and clinically meaningful improvement in psychosocial functioning in response to a psychosocial intervention," the researchers wrote.

Limitations to the study included the lack of blinding,
potential flaws in the symptom assessment instruments,
and the cognitive therapists' high degree of training.

Grant and colleagues also pointed out that the cognitive therapy involved more contact with patients than did the control treatments, which in itself might have contributed to its apparent effectiveness

. Finally, two-thirds of patients in the study were African American and two-thirds were male, possibly limiting the study's generalizability to other groups.

Finding therapists trained in cognitive therapy is a problem. Mr. Grant's group has a contract to train staff members who work with schizophrenic patients at Horizon House and at Temple University Hospital's Episcopal Campus.

One reason the treatment took so much time is that therapists had to work hard to gain patients' trust.Mr. Grant said therapists played video games at the beginning with some clients. If a patient was a little higher functioning, "we might watch Family Guy with him."

Patients were not just more motivated after the treatment. "They were a little more engaged with reality" so their psychotic symptoms improved, Mr. Grant said. The small successes built on one another, offering patients hope for a better standard of living and quality of life.

Researchers believe these patients have more potential than their care providers and family members may have thought possible. According to investigators, the next stage is to train community therapists to deliver the recovery-oriented cognitive therapy in community mental health agencies.

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The predominant patient population in studies has been older, chronic, and mostly male patients with schizophrenia, who may be the least likely to benefit from cognitive enhancement.

Cognitive therapy is a practice without an examined theoretical basis. It is not clear what is the happening that is going on.
Is it that the process is taken at such an easy pace with plenty of time time for rehearsal, a limited first step , and with such companionable support that it is acceptable for those whose memory volume for information dealing, is low - as I put foward from the reduction in their hippocampus neurogenesis - where memory processing is at work.
Or is it that the setting is enhancing the ability, re-establishing an ability in the brains of the subjects to deal with engaging with more 'normalisation.
That is why the more details one learns about papers such as the one by Grant and colleagues, the better what is going on is uncovered.

Another concern is the very high dropout rate in both groups. Dropout across Cognitive Behaviour Therapy of schizophrenia trials normally averages about 15 percent.

Most of the improvement claimed is in the first six motnths when it looks as though this is mostly easing in the introduction - getting the routine of attendance going at a simple level, rather than later when more expectation is put on the subjects.

Then, we do not know enough about what happens next after the sixteen months - say a year later - when all the support from the programme is withdrawn - or is it.